The Spectrum of Ocular Manifestations in Patients with Waldenström's Macroglobulinemia

The wide spectrum of cryoglobulinemic vasculitis and an overview of therapeutic advancements

Immunoglobulins that reversibly precipitate at temperatures below 37 °C are called cryoglobulins (CGs). Cryoglobulinemia often manifests as cryoglobulinemic vasculitis (CV), whose symptoms range in severity from purpuric eruptions to life-threatening features. The majority of CV patients are infected with hepatitis C virus (HCV), whereas lymphoproliferative disorders or connective tissue diseases (CTD) are commonly diagnosed among patients with CV of non-infectious origin. In the absence of detectable associated disease, cryoglobulinemia is classified as "essential" (EMC). All HCV-positive CV patients should be given direct-acting antiviral agents (DAAs) that are consistently able to induce a sustained virologic response (SVR). Glucocorticoids (GCs) can mitigate CV-associated vasculitis, but they have no role as maintenance therapy. Cyclophosphamide restrains the hyperactive phase(s) of the disease and the post-apheresis rebound of newly synthesized CGs. Its use has been largely replaced by rituximab (RTX) in patients unresponsive to DAAs, patients progressing to B-cell non-Hodgkin lymphoma (B-NHL) and patients in whom CV persists or reappears after clearance of HCV. Therapeutic apheresis is an emergency treatment for CV patients with hyperviscosity syndrome. HCV-positive CV patients are at an increased risk of developing NHL, but the achievement of SVR can effectively prevent HCV-related NHL or induce the remission of an already established lymphoma, even without chemotherapy. The treatment of patients with IgM or IgG monoclonal cryoglobulins and an underlying immunoproliferative disorder is based on the regimens adopted for patients with the same B-cell malignancies but without circulating CGs. For patients with CTD, GCs plus alkylating agents or RTX are similarly effective as first-line therapy and in the relapse/refractory setting. In patients with EMC, treatment should consist of GCs plus RTX, with the dose of GCs tapered as soon as possible to reduce the risk of infectious complications.

Sausaging and Bulbosities of the Choroidal Veins in Central Serous Chorioretinopathy

PURPOSE

To evaluate the caliber of the choroidal veins in central serous chorioretinopathy (CSC), a disease proposed to be associated with overloading of choroidal venous outflow.

METHODS

Widefield indocyanine green angiograms of eyes with CSC were graded for sausaging defined as 3 or more contiguous fusiform dilations that vary by at least 50% from the narrowest to largest diameters. A bulbosity was defined as a focal 2X dilation of a blood vessel as compared with the diameter of the surrounding host vessel. The data underwent statistical analysis including use of generalized estimating equations (GEE).

RESULTS

There were 73 eyes of 41 patients with a mean age of 53.5 years. Sausaging of vessels was seen in a mean and median of 3 quadrants per eye. Using GEE, the only significant risk factor for sausaging was use of corticosteroids. The two significant predictors of subfoveal choroidal thickness using GEE were age (P=.021) and proportion of quadrants involved by sausaging (P<.001). The decrease in choroidal thickness per year of age was estimated to be 3.7 µm, while the increase with 4 quadrant involvement with sausaging was estimated to be 236 µm. There was a total of 39 bulbosities in 26 (35.6%) eyes, preferentially involving intervortex venous anastomoses.

CONCLUSIONS

Variations in venous caliber are very common in eyes with CSC and appears to be associated with pathophysiologic alterations related to increased pressure within and remodeling of the larger choroidal veins. This may lead to overloading of the choriocapillaris with leakage as one manifestation.